If you are under 18 years of age, can you provide required proof of your eligibility to work?

Yes

No

Proof of citizenship or immigration status will be required upon employment. (An I-9 form must be completed.)

Have you ever filed an application with us before?

Yes

No

If Yes, give date:

Are you currently employed?

Yes

No

May we contact your present employer?

Yes

No

Are you currently on lay-off status and subject to recall?

Yes

No

Have you ever been convicted of, or pled guilty or no contest to a misdemeanor or a felony such as fraud, embezzlement or misappropriation of funds, or false use of financial instruments, or of any other crime involving honesty?

Yes

No

(An affirmative answer will not necessarily preclude employment.)

If yes, give date, place, charge and disposition:

A criminal background check may be conducted by the Pennsylvania State Police as required by Act 34. Employees may be required to complete Pennsylvania Child Abuse History Clearance forms as required by Act 151.

Step Three – Limitations/Availability

Do you have any limitations regarding hours that you can work?

Yes

No

If Yes, explain:

Do you have any travel restrictions?

Yes

No

If Yes, list and explain them:

Do you have transportation?

Yes

No

Do you have any friends or relatives employed by this company?

Yes

No

If Yes, list name:

When are you available for work?

Step Four – Certifications

First Aid Certification?

Yes

No

Enter First Aid Certification: Expiration Date / Certifying Agency:

CPR Certification?

Yes

No

Enter CPR Certification: Expiration Date / Certifying Agency:

OSHA 10 Hour Construction Safety Certification?

Yes

No

Step Five – Military Service

Branch of Service

Length of Service

Rank/Rate at Discharge

Are you a member of the Armed Services Reserve?

Yes

No

Step Six – Accommodations and Transportation

Are you fully able, with or without reasonable accommodation, to perform the essential functions of the job for which you applied?

Yes

No

Describe how you would perform the job with or without a reasonable accommodation:

Do you have a current Drivers License?

Yes

No

Drivers License State*

Drivers License #

Enter your Drivers License Number.

Class

Expiration Date

List all moving motor violations (other than parking) for the last 3 years:

Step Seven – Education

Enter below each level of education that you have achieved. Those may include: High School or GED, College, Trade School/Other, and Military.

List out the schools you have attended:

Type of School

Name of School

Address of School

Course of Study

Years Completed

Degree / Diploma

Enter each type of school you have completed: High School or GED, College, Trade School, Other, and / or Military

Step Eight – Employment Experience

Enter below each previous employer.

Previous Employment:

Employer

Address

Phone

Date Started

Starting Wage

Starting Position

End Date

End Wage

End Position

Supervisor Name & Title

Reason for Leaving

Job Duties (Briefly)

List Professional, Civic, or Trade

Organization memberships, and any offices held:

References:

Name

Address

Phone

List references.

Step Nine – Voluntary Self‐Identification of Disability

Please check one of the boxes below:*

Yes, I have a disability

No, I don't have a disability

I don't wish to answer

Federal law requires employers to provide reasonable accommodation to qualified individuals with disabilities. Please tell us if you require a reasonable accommodation to apply for a job or to perform your job:

Important Authorization and Understanding

Please read this statement, and acknowledge that you have read it.

Completeness and accuracy of information. I represent that all of the information now or
hereafter given by me in support of my application for employment is true and complete. I understand,
that if I am hired, any false or misleading information in support of my application may subject me to
discharge at any time during the period of my employment.

Authorization for release of information and release from liability. I authorize you to verify
any of the information given during the application process with appropriate individuals, companies,
institutions, or agencies and I authorize them to release such information as you require, including my
prior disciplinary employment record, without any obligation to give me written notice of disclosure. I
hereby release you and them from any liability whatsoever as a result of such inquiries and disclosures.
A photocopy or other electronic reproduction of this authorization/release is binding, and may be relied
upon.

Employment at will. I understand that if I am employed, I will be an employee at will. This
means that either the employer or the employee may terminate the employment relationship with or
without cause at any time.

No written, oral, or implied contracts. I understand that any written Company documents, oral
statements, or formal or informal policies are not to be construed as granting an express or implied
employment contract and that I am not entitled to rely upon any such documents, statements or
Company policies as stating employment terms. The employment relationship with the Company may
be modified only in writing directed to me by the President of the Company.

Benefits may be altered. I understand that the Company at its option may change, delete,
suspend, or discontinue any part or parts of its benefit program at any time without prior notice, both
while persons are actively employed and while retired or otherwise separated from employment with
the Company.

I understand that a test for drug and alcohol misuse may be required as part of the interview
process, and I hereby authorize the release of test results to the Company. I hereby consent to the
performance of such medical examination and testing. I waive all claims arising out of these procedures
against the Company and those performing the examination and tests. I understand and consent that as
a condition of continued employment, I will submit to drug and alcohol testing in the future. I authorize
the release of any such subsequent testing to the Company and waive all claims against it or those
performing the examination and tests. I understand that I will be subject to immediate termination for
failing to submit to examination or testing.

If an employment relationship is established, I agree to wear or use all protective clothing or
devices as may be required by the Company and to comply with all safety policies and procedures.

Confirmation:*

Yes, I acknowledge that I have read and understand the above statement in its entirety, and have had the opportunity to ask questions regarding any aspect .